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Blood Components and Indications for Their Use

Blood Components and Indications for Their Use. Christopher J. Gresens, M.D. VP & Medical Director, Clinical Services BloodSource. 1665 — 1 st Documented Animal-to-Animal Transfusion . Dog-to-dog transfusion by Richard Lower.

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Blood Components and Indications for Their Use

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  1. Blood Components and Indications for Their Use Christopher J. Gresens, M.D. VP & Medical Director, Clinical Services BloodSource

  2. 1665 — 1st DocumentedAnimal-to-Animal Transfusion Dog-to-dog transfusion by Richard Lower. From Petz and Swisher’s Clinical Practice of Transfusion Medicine, 2nd ed., 1989.

  3. 1667—1st DocumentedAnimal-to-Human Transfusion Jean Baptiste Denis infuses 15-year-old boy with lamb’s blood. From Zmijewski’s Immunohematology.

  4. 1818—1st DocumentedHuman-to-Human Transfusion Following a 150-year transfusion hiatus, James Blundell transfuses patient with blood from a human donor. From Petz and Swisher’s Clinical Practice of Transfusion Medicine, 2nd ed., 1989.

  5. 1800’s—All Manner of Blood Collection Devices Utilized (You think present-day donor centers sometimes face challenges in recruiting repeat blood donors?) From Petz and Swisher’s Clinical Practice of Transfusion Medicine, 2nd ed., 1989.

  6. 1900—ABH Blood Group System ID’d Karl Landsteiner discovers ABH system when he types individuals as (what we now call) group A, group B, and group O. In 1902, his proteges identify a group AB individual for the first time. From Transfusion, Vol. 1, p. 2 (1961)

  7. The Discovery of Many OtherRed Cell Antigens Followed • Rh (C, c, D, E, e, …) • Kell (K, k, …) • Kidd (Jka, Jkb, …) • Duffy (Fya, Fyb, …) • MNSs, … • Lewis (Lea, Leb) • … … …

  8. Early 1900’s—Getting Blood from Point A to Point B Direct, donor-to-patient anastamosis performed by American surgeon, George Crile. From Petz and Swisher’s Clinical Practice of Transfusion Medicine, 2nd ed., 1989.

  9. 1914—Modern Anticoagulation is Born Citrate first used for blood anticoagulation purposes. From Petz and Swisher’s Clinical Practice of Transfusion Medicine, 2nd ed., 1989.

  10. 1939/40—Rh and Cause of HDFN Discovered Levine, Wiener, and colleagues combined their efforts in making these seminal discoveries From Netter Monograph Series

  11. But, the importance of ABO supersedes all … From Petz and Swisher’s Clinical Practice of Transfusion Medicine, 2nd ed., 1989.

  12. Outline Blood Collection and Component Preparation • Blood Collection • Whole Blood Separation into Components • Apheresis • Blood Bag Solutions • Donor Testing

  13. Outline Major Types of Blood Components/Derivatives • Whole Blood ·Cryoprecipitate • Red Blood Cells (RBCs) · Granulocytes • Platelets · Derivatives • Fresh Frozen Plasma (FFP)

  14. Outline Specialized Types of Blood Components & Transfusions • Irradiated Blood • CMV-seronegative Blood • Leukoreduced Blood

  15. Blood Collection &Component Preparation Blood Collection 1. Via Whole Blood Donation: Whole blood is collected from healthy blood donors into sterile blood bags that contain anticoagulant/preservative. 2. Via Hemapheresis: Machines with internal centrifuges separate a donor’s blood into individual components. The desired components are retained, while the remainder is returned to the donor.

  16. Four-BagCollection System for Whole Blood

  17. + “Light” Spin = …

  18. + “Heavy” Spin = …

  19. FFP vs. … ?

  20. … Cryoprecipitate

  21. Apheresis-Assisted Donor CollectionTrima/Trima Accel • Used for donor procedures, only (single- or double-RBC units; single-triple plateletpheresis, and/or plasma) From Gambro BCT website

  22. The Principles of Hemapheresis

  23. Blood Bag Solutions • Purpose of Anticoagulant-Preservatives • To prevent clotting • To provide nutrients for continued metabolism and stabilization of cells • Basic Needs of Stored Blood Cells • Adequate glucose (dextrose) • Adequate ATP levels • Appropriate pH

  24. Blood Bag Solutions • The Storage Lesion: These are the metabolic changes that occur to stored blood over time. Following is an example for CPDA-1 RBCs. Parameter0 Days35 Days % Viable Cells 100 71 pH 7.55 6.71 [K+] (mmol/L) 5.1 78.5 [Plasma Hgb] (mg/L) 78 658 [2,3-DPG] (% of initial) 100 < 10 AABB Technical Manual, 14th ed.

  25. Testing • ABO • Rh • Antibody Screen • Infectious Diseases • Syphilis • HBsAg • Anti-HIV-1/2 • Anti-HBc

  26. Testing • Infectious Disease Testing (cont.) • Anti-HTLV-I/II • Anti-HCV • HIV Nucleic acid testing (NAT) • HCV NAT • HBV NAT • WNV NAT • Anti-T.cruzi • (On some units) Anti-CMV

  27. Currently Accepted Risksof Transfusion • Acute immune-mediated hemolytic transfusion reactions:1 in 19,000 risk for ABO mismatched transfusion; 1 in 33,000 for major ABO mismatch; 1 in 600,000 for death (Linden et al. Transfusion 1992; 32: 601-606) • TRALI:1: 300 to 1:5,000 (Kao S, et al. Transfusion 2003; 43: 185-191) • Septic transfusion reactions:< 1: 777 plateletpheresis units; 1: 38,565 RBC units (Infectious Risks of Blood Transfusion. Blood Bulletin (America’s Blood Centers), December, 2001) • Anaphylactic transfusion reactions:1: 20,000 to 1:47,000 (Salama A, et al. Transfusion 2004; 44: 509-511)

  28. Transfusion Risks(Continued) • Circulatory overload • Allergic transfusion reactions • Febrile nonhemolytic transfusion reactions • Delayed hemolytic transfusion reactions • Transfusion-related graft-versus-host disease • Post-transfusion purpura

  29. Transfusion Risks(Continued) • HIV: 1 in 2,135,000 units • HBV: 1 in 205,000-to-488,000 units • HCV: 1 in 1,935,000 units • HTLV-I/II: 1 in 514,000-2,993,000 units • CMV: << 1: 100 (when leukoreduced or CMV-negative blood used) • WNV: ? (region-specific; very low) • vCJD: ? (risk very, very low—even in U.K.) “Infectious Risks of Blood Transfusion.” Blood Bulletin (America’s Blood Centers). December 2001.

  30. Top-10 Reasons for Giving Blood 10. It makes me feel good about myself. 9. How else can I instantly lose one pound? 8. To put up my feet and relax without guilt. 7. All my friends & family do it, so I do, too. 6. It’s a nice way to meet people with similar philosophies.

  31. Top-10 Reasons for Giving Blood 5. The good-looking nurses (and doctors). 4. Because, even though I have few material possessions to give, I always (God willing) will have enough blood to share. 3. Because I know that, whatever they take from me, I can replace. 2. How else can I experience so much satisfaction with my clothes on?

  32. …and the Number 1 Reason for Giving Blood 1. To help save the lives of others.

  33. Whole Blood • Clinical Indications: Provides both O2 delivery and volume in patients with hypovolemic shock. • Contraindications • Thrombocytopenia (unless unit is VERY fresh) • Factor VIII or V deficiencies • Normovolemic chronic anemia

  34. Whole Blood • Transfusion Criteria • Must be ABO-identical • Should be crossmatch compatible • Dosage: One unit should raise a 70 kg patient’s Hct by approximately 3% (in the absence of ongoing bleeding or hemolysis).

  35. “Shotgun” Approach vs. . . .

  36. Component Therapy

  37. Recommended Target Hematocrits for RBC Transfusions(To be Revisited) • Clinical Indications: To restore O2-carrying capacity in clinically significant (acute or chronic) anemias. • Asymptomatic anemia: Typically, in stable patients, Hgb thresholds of 7-to-8 g/dL should be crossed before transfusion would be considered. • Bleeding/acute blood loss: Transfuse at the discretion of physician. • Occasional exceptions, such as the need to transfuse pre-renal transplant patients, regardless of their Hcts (i.e., to induce immune tolerance), exist.

  38. Recommended Target Hematocrits for RBC Transfusions (Revisited) • Lower limit (or “transfusion trigger”) for general medical and surgical patients remains at Hgb (Hct) levels of 7.0 g/dL (21%). • Some patient groups (e.g., elderly with acute MI’s) seem to have better outcomes when Hct is in 30-33% range. “Current data suggest restraining transfusions favors positive patient outcomes—except when significant underlying cardiac disease is present.” “The Transfusion Trigger Updated: Current Indications for Red Cell Therapy.” Blood Bulletin, Vol. 6; July, 2003.

  39. RBC Transfusions • Contraindications • Pharmacologically treatable anemias • Most coagulation deficiencies • Transfusion Criteria • Must be ABO-compatible (group O is “universal”); • Should be crossmatch-compatible; • Dosage: One unit generally will raise the Hct (Hgb)of a 70-kg, non-bleeding/hemolyzing patient by 3%(1 g/dL).

  40. Clinical Indications for Platelets • Overview: Platelet transfusions are used for the treatment and/or prevention of bleeding in patients with thrombocytopenia or (less often) platelet function defects

  41. Clinical Indications for Platelets 1910: Duke demonstrated that platelets from transfused whole blood decrease bleeding time and control bleeding.1 1962: Gaydos, et al. first documented relationship between platelet count and spontaneous bleeding in leukemia patients (hemorrhage not seen until platelet count fell to < 50,000/uL).2 1. Duke WW. JAMA 1910; 55: 1185-92. 2. Gaydos, et al. NEJM 1962; 266: 905-9.

  42. Clinical Indications for Platelets 1978: Slichter & Harker showed that blood loss in stable aplastic patients accelerated only when platelet count < 10,000/uL (moreover, bleeding increased substantially with platelet count of < 5,000/uL).1 1986: NIH-Sponsored Consensus Conference …2 Plt ct > 50,000: Bleeding probably not due to low plt ct Plt ct < 5,000: Severe bleeding risk Plt ct 5-10K: risk of spontaneous bleeding Plt ct 10-50K: risk of bleeding during hemostatic challenge • Slichter & Harker. Clin Hemat 1978; 7: 523-39. • Consensus Conference on Platelet Transfusion Therapy. JAMA 1987; 257: 1777-80.

  43. Clinical Indications for Platelets A. Guidelines for Prophylactic Platelet Transfusions 1. No Clinical Factors—Maintain platelet count > 10,000/uL 2. Significant Clinical Factors (e.g., sepsis, DIC, VOD, GVHD)—Maintain platelet count > 20,000/uL B. If Patient is Bleeding or Pre-Surgery, maintain platelet count > 50,000/uL C. Exceptions … (To be discussed)

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